VIVID-Med: LLM-Supervised Structured Pretraining for Deployable Medical ViTs

Vision-language pretraining has driven significant progress in medical image analysis. However, current methods typically supervise visual encoders using one-hot labels or free-form text, neither of which effectively captures the complex semantic relationships among clinical findings. In this study, we introduce VIVID-Med, a novel framework that leverages a frozen large language model (LLM) as a structured semantic teacher to pretrain medical vision transformers (ViTs). VIVID-Med translates clinical findings into verifiable JSON field-state pairs via a Unified Medical Schema (UMS), utilizing answerability-aware masking to focus optimization. It then employs Structured Prediction Decomposition (SPD) to partition cross-attention into orthogonality-regularized query groups, extracting complementary visual aspects. Crucially, the LLM is discarded post-training, yielding a lightweight, deployable ViT-only backbone. We evaluated VIVID-Med across multiple settings: on CheXpert linear probing, it achieves a macro-AUC of 0.8588, outperforming BiomedCLIP by +6.65 points while using 500x less data. It also demonstrates robust zero-shot cross-domain transfer to NIH ChestX-ray14 (0.7225 macro-AUC) and strong cross-modality generalization to CT, achieving 0.8413 AUC on LIDC-IDRI lung nodule classification and 0.9969 macro-AUC on OrganAMNIST 11-organ classification. VIVID-Med offers a highly efficient, scalable alternative to deploying resource-heavy vision-language models in clinical settings.

PRISM: Festina Lente Proactivity -- Risk-Sensitive, Uncertainty-Aware Deliberation for Proactive Agents

Proactive agents must decide not only what to say but also whether and when to intervene. Many current systems rely on brittle heuristics or indiscriminate long reasoning, which offers little control over the benefit-burden tradeoff. We formulate the problem as cost-sensitive selective intervention and present PRISM, a novel framework that couples a decision-theoretic gate with a dual-process reasoning architecture. At inference time, the agent intervenes only when a calibrated probability of user acceptance exceeds a threshold derived from asymmetric costs of missed help and false alarms. Inspired by festina lente (Latin: "make haste slowly"), we gate by an acceptance-calibrated, cost-derived threshold and invoke a resource-intensive Slow mode with counterfactual checks only near the decision boundary, concentrating computation on ambiguous and high-stakes cases. Training uses gate-aligned, schema-locked distillation: a teacher running the full PRISM pipeline provides dense, executable supervision on unlabeled interaction traces, while the student learns a response policy that is explicitly decoupled from the intervention gate to enable tunable and auditable control. On ProactiveBench, PRISM reduces false alarms by 22.78% and improves F1 by 20.14% over strong baselines. These results show that principled decision-theoretic gating, paired with selective slow reasoning and aligned distillation, yields proactive agents that are precise, computationally efficient, and controllable. To facilitate reproducibility, we release our code, models, and resources at https://prism-festinalente.github.io/; all experiments use the open-source ProactiveBench benchmark.